NCCNHR Minimum Staffing Standards

The NCCNHR Staffing Standards. In 1998, NCCNHR members voted to support the following minimum nurse staffing ratios developed in consultation with long term care experts over a period of years. Since then, these standards have been used, as intended, as “a model framework for state and federal action” – introduced in several congressional bills and used as a framework in the debate in a number of state legislatures that have enacted state staffing standards.

These “NCCNHR Staffing Standards” – which call for nursing home residents to receive at least 4.13 hours of direct nursing care each day – have been validated by the research conducted by independent researchers for the government study of the Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes.

PROPOSED MINIMUM STAFFING
STANDARDS FOR NURSING HOMES*

(Adopted by the NCCNHR Membership, November 1998)

WHEREAS, adequate nursing staff is needed for quality care, and

WHEREAS, the role of the nurse aide and nurse are clearly defined in the delivery of quality of care, and

WHEREAS, nursing home residents need 24 hour care every day, seven days a week, and

WHEREAS, minimum standards not be treated as maximums, and that actual staffing levels be sufficient to enable each resident to achieve the highest practicable quality of care and quality of life,

THEREFORE BE IT RESOLVED, that these standards be adopted by the NCCNHR membership as a model framework for state and federal action:

Administration Standard

A full-time RN with a Bachelor's Degree would be the Director of Nursing

    (A provision for grandfathering current RN Directors would be allowed for a specified time period)

A part-time RN Assistant Director of Nursing (full-time in facilities of 100 beds or more)

    (This person may also be the MDS coordinator)

A part-time RN Director of In-Service Education (preferably with adult education and gerontology training)

    (Full-time in facilities of 100 or more)

A full-time RN nursing facility supervisor must be on duty at all times, 24 hours per day, 7 days

per week.

Direct Care Staffing Standard

The minimum number of direct care staff must be distributed as follows:
    Minimum Level Direct Care Staff (RN, LVN/LPN, or CNA):

Day Shift 1 FTE for each 5 Residents (1.60 hours per resident day)
Evening Shift 1 FTE for each 10 Residents (0.80 hours per resident day)
Night Shift 1 FTE for each 15 Residents (0.53 hours per resident day)

    Minimum Licensed nurses (RN and LVN/LPNs) providing direct care, treatments and medications, planning, coordination and supervision at the unit level:

Day Shift 1 FTE for each 15 Residents (0.53 hours per resident day)

Evening Shift 1 FTE for each 20 Residents (0.40 hours per resident day)

Night Shift 1 FTE for each 30 Residents (0.27 hours per resident day)

The minimum total number of direct nursing care staff would be 4.13 hours per resident day.

These requirements should be in place for all residents, regardless of payment source and no waivers of these standards should be allowed. (Administrative staff would be excluded from the direct care standard except in facilities with 30 or less residents).

Nurses and nurse aides must be counted only once in determining the adequacy of staff in skilled nursing facilities and nursing facilities that operate non-nursing units and home agency services.

Staffing must be ADJUSTED UPWARD for residents with higher nursing care needs. For example, residents classified under the Resource Utilization Groups (RUGs) as being in the category requiring extensive nursing care received an average of 6.2 hours of nursing time per resident day in the 1995-1997 time studies.**

Mealtime Nursing Staff

Direct care staffing standards will take into account specific needs of residents at mealtimes. At all mealtimes, there will be:

    1 nursing FTE for each 2-3 Residents who are entirely dependent on assistance.
    1 nursing FTE for each 2-4 Residents who are partially dependent on assistance.

Residents must be encouraged to remain as independent as possible in feeding themselves, and this may require more staff time than would be required if residents were fed entirely by someone. Nursing staff who assist with feeding must be certified nursing assistants who are adequately trained in feeding procedures and they must be supervised by licensed nurses.

Education and Training

All licensed nurses in nursing homes must have continuing education in care of the chronically ill and disabled and/or Gerontological nursing (at least 30 hours every two years).

Nursing assistants should have a minimum of 160 hours of training, including training in appropriate feeding techniques (at least 12 hours relevant training every year).

Nurse Practitioners

Each nursing home is strongly urged (but not required) to have a part-time Geriatric or Adult Nurse Practitioner and/or a Geriatric Clinical Nurse Specialist on staff (full-time for 100 beds or more).

Disclosure: Public Right to Staffing Levels

• A long-term care nursing facility shall post for each wing and/or floor of the facility and for each shift the current number of licensed and unlicensed nursing staff directly responsible for resident care and the current ratios of residents to staff, which show separately the number of residents to licensed nursing staff and the number of residents to (direct caregivers) unlicensed staff. This information shall be displayed on a uniform form supplied by the licensing agency.
 
• Such information shall be posted for the most recently concluded cost reporting period in the form of average daily staffing ratios for that period.
 
• This information must be posted in a manner that is visible and accessible to all residents, their families, caregivers and potential consumers in each facility.
 
• A poster provided by the licensing agency which will describe the minimum staffing standards and ratios (listed above) shall also be posted in the same vicinity.
 
• A list, in at least 48 point type, showing the first and last names of nursing staff on duty shall be posted at the beginning of each shift prominently on each unit.

* Builds on the Nurse Staffing Standards accepted by the National Citizens' Coalition for Nursing Home Reform, 1995.

** 1995-1997 HCFA time studies found about 8 percent of residents were in the RUGs category that requires extensive nursing care. Approximately 50 percent of the time for the extensive nursing residents in the HCFA 1995-1997 national time studies were for licensed staff and of that 57 percent was for RN time. For residents in the rehabilitation RUGs category, the nursing time spent averaged 5 hours per resident day, of which 50 percent was for licensed staff time and, of that, 50 percent was RN time.) Burke, B. , and Cornelius, B. 1995 and 1997 Staff Time Measurement Study. Baltimore, MD: Health Care Financing Administration Multi-state Casemix Demonstration Project, August 1998.